Childhood Vaccines – part 2 – PediaCast 352

Show Notes

Description

Dr Michael Brady returns to the PediaCast Studio for part 2 of our discussion on childhood vaccines. Today we cover Influenza, Measles, Mumps, Rubella, Chickenpox, Hepatitis A, Meningococcal and HPV. We also explore common concerns for moms and dads: are kids getting too many shots? Can their immune systems handle these injections? And what about alternate vaccine schedules? We hope you can join us!

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Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.

It is Episode 352 for September 7th, 2016. We're calling this one "Childhood Vaccines Part 2". I want to welcome everyone to the program.

As you can tell from the title, today's episode is a continuation from our last time together, as we continue our journey through the world of childhood vaccines. So, if you want the big picture and you haven't listened to Part 1, I would encourage you to go back and listen to our previous podcast. Again, Episode 351. This one's 352.

On the other hand, maybe you're here because you want information on a specific vaccine that we're covering today. Maybe you don't care about the big picture and all the rest. If that's the case, no problem, we're glad you're here as well. Or maybe listen to this one first and then go back to the previous show. That also works just fine.

The point here really was to provide a couple of episodes where moms and dads could come — episodes with information from a comprehensive trustworthy evidence-based source on the whole of routine child vaccines and the diseases that they prevent.

So there's no big pharma support here. I don't make any money on immunizations at all. There aren't any conflicts of interest. We just want to share what we know including the risks when there are risks. But we also want to put those risks into perspective and compare them with the benefits, so you can do a risk-benefit analysis and really make an informed decision.

0:02:11

So, if you're interested in that sort of information, risks and benefits, you'll definitely want to go back to Part 1, Episode 351, over at PediaCast.org. Because we do hit the benefits and risks in considerable detail before we dive into these specific vaccines and their corresponding diseases.

Speaking of those specific vaccines and diseases, last time, we talked about hepatitis B, diphtheria, tetanus, pertussis or whooping cough, also polio, rotavirus, pneumococcus and Haemophilus Influenza, which we pointed out is different than the real flu.

So today, we're going to move to cover the MMR vaccine, which means measles, mumps and rubella. Speaking of that vaccine, we'll mention the MMR-autism controversy, but we won't spend too much time there. Not because I want to avoid it but because we had Seth Mnookin in the studio not too long ago talking about his book, The Panic Virus: The True Story Behind the Vaccine-Autism Controversy.

Seth, you remember is a New York Times bestselling author and investigative journalist who did a lot of digging to uncover the events surrounding Dr. Andrew Wakefield's proclamation — false, by the way — that the MMR vaccine was associated with autism. That was back in the 1990s.

Of course, now we know Dr. Wakefield's work was largely fraudulent. Significant conflicts of interest were exposed. The journal, Lancet retracted the study. He lost his medical license and multiple large well-designed studies done since that time have not shown an association between any vaccine and autism.

So interesting stuff. As I mentioned, last week, definitely a major event in medical history. And it's one that still has an effect or an influence on many families today. If you want to learn more about the details surrounding that story, you'll definitely want to listen to my interview with Seth Mnookin, PediaCast 329. We call that one The Vaccine War. And I'll put a link to it in the Show Notes for this episode, 352, over at PediaCast.org.

0:04:15

So, we'll talk about the MMR vaccine, but we'll mostly keep to the facts surrounding the vaccine and the diseases that prevents measles, mumps and rubella. We'll also cover the varicella vaccine, which prevents chicken pox, also influenza — the real flu as opposed to Haemophilus Influenza type b which we covered last week — hepatitis A, the meningococcal vaccine (which protects against some forms of meningitis), and immunizations for HPV (which is the human papillomavirus). We'll talk about that one in considerable detail, as well do with all the others.

But parents and teens do have lots of questions about the HPV vaccine — why is it important? What risks might be involved? And we won't shy away from the controversies surrounding the HPV vaccines, because we want you to have all the information that we know, so that you can make an informed decision.

So that's coming up. And like last time, we have a fantastic guest joining us in the studio. Dr. Michael Brady is back to help us sort through the childhood vaccines. He's a pediatric infectious disease expert at Nationwide Children's. He has served as past Chair of the American Academy of Pediatrics Committee on Infectious Disease and associate editor of The Red Book, which as my fellow health care providers in the audience know, is the go-to infectious disease reference in the world of pediatrics. So, in other words, we have an infectious disease and childhood immunization superstar joining us today.

Before we get to Dr. Brady, I do want to remind you, it is easy to get in touch with me. If you have a question for the program, or you'd like to suggest a topic for a future show, it's easy to get in touch. Just head over to PediaCast.org and click on the Contact link. We also have a voice line if you'd like to leave your message that way, and that number is 347-404-KIDS.

0:06:05

Also, I want to remind you, the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So, if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at PediaCast.org.

Let's take a quick break. We'll get Dr. Michael Brady settled into the studio and return to talk more about childhood vaccines. That's coming up, right after this.

[Music]

Dr. Mike Patrick: Dr. Michael Brady is an infectious disease specialist at Nationwide Children's Hospital and a professor of Pediatrics at The Ohio State University College of Medicine. He served as Chair of the Department of Pediatrics at Ohio State from 2005 until 2013. And he's also a past Chair of the American Academy of Pediatrics Committee on Infectious Disease.

Dr. Brady is currently an associate editor of the Red Book, which is the comprehensive infectious disease reference from the AAP. And he's a candidate to be the next president of the American Academy of Pediatrics.

You won't find a more qualified guest to talk about childhood vaccines and the diseases they prevent. So, let's give a warm returning welcome to Dr. Michael Brady. Thanks for joining us again today.

Dr. Michael Brady: Thanks for having me. I appreciate the opportunity.

Dr. Mike Patrick: Yup, really appreciate you stopping by.

As I mentioned, you're running for president of the American Academy of Pediatrics. And we're going to talk with you more about that at the American Academy of Pediatrics National Conference and Exhibition. It's in October of this year, 2016, in San Francisco. I'll be podcasting from the Nationwide Children's booth in the exhibition hall. We're going to talk to Dr. Brady at that time and get that interview out to you in October about the state of pediatrics today — what are the most pressing challenges for doctors and parents and kids and what we can do to meet those challenges? So stay tune for that.

0:08:28

By the way, if you are a pediatric provider and plan on attending the AAP conference in October in San Francisco, please stop by the Nationwide Children's booth in the exhibition hall and say hello. And we'd even like to get you on the podcast, really sharing your joys and challenges as a pediatric provider. Really, we're going to ask a lot of you those same questions — what are the most pressing issues right now and how are you dealing with those in your practice?

So we'll be recording some special shows, hopefully featuring lots of pediatric providers from the convention hall in San Francisco. Again, that's in October. So hopefully, you can join us there.

So, let's get to back to it with Dr. Brady. We have lots to cover today. And it's a good time of the year to start talking about the flu vaccine. Now, this is vaccine that kids have to get every year. Why the flu vaccine? Why isn't that just like these other ones — you get two, four months, six months, kind of thing and then a booster or two here? You have to get a flu shot every year. Why is that?

Dr. Michael Brady: So, there's actually kind of two different reasons. Probably the most important reason is the fact that the influenza virus has a unique structure that allows it to make either minor or major changes much more frequently than many of the other infections. And so, one of the things that happens is almost every year, the vaccines that are circulating in the northern or the southern hemisphere are slightly or significantly different than the vaccines that were circulating the year before or two years before.

And so, if you want to have protection against the influenza virus that's going to be circulating in usually the winter time in northern hemisphere, you have to have one that's specifically designated to address the potential strains that are going to be circulating. And again, they change almost every year. And so, we need to do that.

0:10:27

The other situation is that with the current vaccines, they usually only have kind of antibody protection for about a year. And so, there are people working on what will be called universal influenza vaccine where you could develop a vaccine against components of the influenza virus that don't change from year to year. And they would probably try to figure out how to make it so that you might not need to get vaccinated every year, but maybe every five years, ten years or something like that. And we're not that far away from that, but for right now, we do need to get the influenza vaccine and we need to get it every year.

One of the things that pediatricians need to be aware of is influenza is currently the vaccine-preventable illness that's going to cost the most deaths in children. And so, a lot of times, people kind of downplay influenza as a vaccine and a lot of times, parents will not be excited about receiving it. And pediatricians need to be aware of the fact that every year, a 100 to 200 children actually die from influenza.

Dr. Mike Patrick: So it's the leading cause of vaccine-preventable diseases.

Dr. Michael Brady: Yeah.

Dr. Mike Patrick: Now, there's two types of influenza vaccine and it's been in the news this year that the nasal types — so it's a spray that goes up your nose and that one is a live virus — versus the shot form which is a killed or inactivated virus, that the killed one is the better one to get this year.

Dr. Michael Brady: Yes. So the shot.

Dr. Mike Patrick: Rather than the nose spray.

0:12:15

Dr. Michael Brady: Exactly. So everybody was excited about having influenza vaccine that didn't need a shot, because nobody's excited about a shot. And when it first came out, it really looked like it was going to be the answer. You gave the vaccine into the nose which is usually the kind of point of entry of the virus. You develop a very kind of strong immune response there. And so, it looked like it was going to be actually maybe the better of the vaccines. And if you can remember, two years ago, the CDC even made it a preference for the vaccine.

Well, as was mentioned, the CDC and other situations, they monitor things very closely and try to look at how well the influenza vaccines work. Now, in general, people will talk about the fact that the efficacy of influenza vaccines usually runs around 60%, which may not sound very good. But because typically in a season, if you don't have people being immunized, there might be 40 or 50 million people who get influenza. If you can reduce 60% of that, and particularly reduce it in people who are more vulnerable to influenza, it makes a huge difference.

Well, when they were looking at the vaccine efficacy over the last three seasons, it turned out that the live attenuated influenza or nasal vaccine didn't do very well. And it isn't really clear why that is. So, one concern was the fact that the vaccine had, because it's live, some potential related to the virus when it multiplied may have had some kind of weak point and didn't really respond as well as people wanted.

0:14:15

That was one possibility. But I think one of the things that we're learning is in order for the vaccine to work, it has to multiply within the nose. So you give a small amount, it multiplies and creates a much larger amount of this weakened but still immunogenic virus in the nose. And when the first days were done, children were not routinely given influenza vaccines, so most of them weren't immunized. So it's usually the first time they've ever been exposed to new influenza vaccine, so they had a very good response.

But now, you're giving this particular vaccine to people who've had influenza vaccines before. And probably it interferes with the ability of the virus to replicate and produce enough antigen to become protected.

So there probably are some opportunities to try to learn from that and figure out how to modify that. But, the fact that for three years in a row, it really didn't look very good meant that it probably shouldn't be an option. And we really don't like to do that. We want to make sure that everybody gets immunized against influenza. And there are some people who just really don't like shots. So, it's very tough to take an option off the table that might get people to accept the influenza vaccine. But it really did look like it would not be appropriate to actually say it's an option.

Dr. Mike Patrick: So this is really a situation where pediatricians can explain to parents this is why. I think those are great explanation of why the shot is better right now than the nasal form of it. Because that is an issue when you have a kid, especially the older ones who know what shots and really don't want one. So, to try to explain to the parent why you need to do this, I think that's great. Great information.

0:16:19

Let's move on to the MMR vaccine. Tell us about that one.

Dr. Michael Brady: So MMR stands for measles mumps and rubella. Those are three relatively — prior to the MMR vaccine — common childhood illnesses. Two of them, measles and rubella would cause what we call an exanthem rash with high fever. And mumps is when we get swelling of the parotid glands and other glands, as well as potentially involvement of ovaries and the testes.

So these vaccines were developed by taking the virus and modifying it by a process called attenuation to make it so that it will be safe to give them without causing the disease but causing the immune system to respond to that.

Now, measles is probably the one that is most important. There's an estimate now that worldwide, the measles vaccine prevents one million deaths a year. Now, many of those will occur in non-industrialized countries but we did see significant diseases related to measles. And I actually had measles as a child and can remember walking around with sunglasses because my eyes hurt so much. And I ached and had high fevers.

So, measles can be a very serious disease. You already mentioned one of the potential long-term complications last week, the sub-acute sclerosing panencephalitis, but we would see measles pneumonias and other problems.

0:18:07

Rubella, which is the second one, probably isn't as much of a problem for the individual who gets it but it was clearly a needed vaccine. Because if women who are pregnant get rubella, it can cause significant damage to their fetus and their baby would be born with significant problems. It affects the brain. It affects the heart. It affects the eye. And so, it was a significant problem.

And actually, the impetus to the rubella vaccine was a huge worldwide rubella epidemic in 1963 and 1964. And there were very, very many pregnant women who got infected and had damaged children, not to dissimilar to where our concern about is going to happen with Zika. So, there was a huge impetus to develop the rubella vaccine. And right now, congenital rubella syndrome in the United States is pretty much unheard of.

The last one is mumps. And again, for the average person, this may not be a major problem. It gives you a couple of days of discomfort, maybe some arthritis, but it can affect ovaries and the testes, which can result in infertility. This is one where we're kind of currently having a little bit of issue around how long do you get protection. Because right now, really, we aren't seeing significant problems related to measles or rubella in closed populations with high immunization rates, but we have seen some outbreaks of mumps in colleges.

And so it does appear that probably, you get really good protection up until the late teen years. And, fortunately, if we do maintain high levels of immunity, there won't be mumps circulating in order to potentially infect college students or other military people, or other people in closed populations.

0:20:21

So, again, this is another situation where community protection would be really, really, valuable. And fortunately again, these outbreaks are very, very unusual, but they've been in the media recently.

Dr. Mike Patrick: It's rare but it can cause encephalitis and meningitis and hearing loss, too. And again, the numbers may be little, but if you're the one that it happens to, you sure wish that you had been protected and not had that occur.

And then, I also wanted to look at some of the numbers with measles. All of these, measles, mumps and rubella, being viruses, these particular viruses, there's no treatment other than supportive care when you get these, correct?

Dr. Michael Brady: That's correct.

Dr. Mike Patrick: So there's no antibiotic that you can give to treat. And even in developed countries, the mortality rate or death rate from measles is 1 to 2 in every 1,000 cases, which ends up being .1% to .2% mortality rate. But that's in developed countries with modern healthcare and supportive care in the hospital.

So, these things can still be deadly, and in particular, measles. And again, low numbers, but those numbers don't mean anything if it's your family that's affected by that.

So the MMR vaccine given at 12 to 15 months of age and then a booster before kindergarten, sort of 4 to 6 years of age. And we're not going to talk at this time about the autism-MMR controversy. Again, I would refer folks to the episode PediaCast 329, The Vaccine War, where I interviewed Seth Mnookin. He's a New York Times bestselling investigative reporter and author. He has a book called The Panic Virus: The True Story Behind the Vaccine-Autism Controversy. And we'll put links in the Show Notes of Episode 352 over at PediaCast.org, if you'd like to listen to the episode of my interview with Seth.

0:22:20

Dr. Michael Brady: Can I say one more thing about measles?

Dr. Mike Patrick: Yeah, absolutely.

Dr. Michael Brady: Americans have a tendency to like to travel. And many of the areas around the world still have measles, even in many of developed countries. So, one of the things that's important, as you mentioned, we usually give the first dose of the measles vaccine at 12 months of age, and then the second dose can be given any time after four weeks after that. But typically, it's given right before school.

If you have child who is 6 months of age to 12 months of age and hasn't yet received their measles vaccine, and you're going to take them outside of the United States, they should get a dose of the measles vaccine before they travel. Now, that doesn't count for the two vaccines that they need in order to get into school entry. But we have seen a number of young infants actually return from travelling and they've gotten measles.

Dr. Mike Patrick: And the reason they wouldn't count is because it gives them temporarily protection but you still need those two to get long-lasting protection from measles.

And then, last week, we mentioned the Disneyland measles outbreak. And that really was because there were so many unimmunized kids in the community that could pass that, get infected, and pass it on to other kids.

Dr. Michael Brady: Right. And that actually is kind of… It's never nice to have an outbreak, but one of the things that created a lot of the clusters was the significant numbers of people who had non-medical exemptions for getting into school without their vaccines. And that prompted the state of California to actually significantly, actually eliminate philosophical objections and to eliminate the non-medical exemptions. And I think we're going to benefit from that.

0:24:14

Dr. Mike Patrick: In terms of MMR, the one that sort of now goes along with that and is often given around the same time is the varicella vaccine, or the vaccine that protects against chicken pox. And I remember when this vaccine came out, prior to that, there were a lot of folks who would intentionally their kids to chicken pox just to get it over with. Or, maybe make it more convenient that it would happen in the summer, so it wasn't during the school year. But chicken pox can be a serious disease for some, right?

Dr. Michael Brady: Yes. Again, as you mentioned, the chicken pox parties, et cetera, that was based on the fact that, again, people recognized that if you got chicken pox once, you wouldn't get it again. But I think that people weren't familiar with all the potential situations that occur related to varicella.

So, first of all, even healthy children can go on to develop significant consequences from varicella. And I had mentioned last week about varicella encephalitis. It was not unusual — every spring when chicken pox is more common — for us to have many children on the infectious disease wards with very, very severe cellulitis and even necrotizing fasciitis, the so called flesh-eating bacteria that occurred when chicken pox scabs were infected. So even healthy children can have consequences.

But the other situation is it's a real risk for patients whose immune systems aren't capable of controlling the virus. Cancer patients are probably the most common in pediatrics. But there's are other medical conditions that can impact your ability to fight infections, and varicella can be more severe.

0:26:04

The other situation is that shingles or zoster can occur from a reactivation of infection, following infection with varicella or chicken pox. And it's particularly severe in adults, particularly older adults. And there's pretty good data right now to suggest that getting the live virus vaccine markedly reduces the likelihood that you would develop zoster compare to having natural infection. So, it can have a direct impact on reducing chicken pox, but also potentially one of its long-term complication, zoster.

Dr. Mike Patrick: Because when you have that virus, some of it can stay dormant in the nerves, and then when that gets reactivated years down the road, then you can get herpes zoster shingles. So when you're getting your kids the varicella vaccine against chicken pox, you're also to some degree protecting them against shingles when they're older. Good point.

Another vaccine that kids get is the hepatitis A vaccine. Tell us about that one.

Dr. Michael Brady: So hepatitis A is a vaccine that prevents a type of hepatitis or inflammation of the liver that's usually acquired through what's called fecal oral transmission. So, it's something that you might pick up. Again, in childcare centers, it was pretty prevalent. But also, potentially, you can get it if you go to a country where the water isn't well-treated. Or even in the United States, there's somebody who has hepatitis A. We've seen outbreaks associated with contaminated foods. Also, we now have a lot more fruits and vegetables coming from countries where they actually fertilize using human excretia as the fertilizer.

0:28:06

Dr. Mike Patrick: I don't like to think about that.

Dr. Michael Brady: But it's used. And so, we've seen outbreaks, raspberries and other things with hepatitis A. So, hepatitis A, for the most part, causes a relatively self-limited infection of the liver. It doesn't cause chronic disease like hepatitis B and hepatitis C. But people have gotten severe hepatitis and they've even gone into hepatic encephalopathy where the liver damage causes changes in the brain, et cetera. And again, it can occur in significant outbreaks, and that can be kind of very troubling to communities, et cetera.

So the vaccine was developed and it is very effective at protecting people and can be used just on a kind of a routine base, just as part of the immunization schedule. But if you've been exposed to somebody with hepatitis A, it can be used to prevent in that circumstance as well because of the incubation period being long enough for the vaccine to be able to be protected.

Dr. Mike Patrick: This is another instance where the monitoring systems are important because the hepatitis A vaccine just began around the year 2000 or so. So in terms of how long is the protection going to last it's going to be important to monitor that, to know if boosters doses are needed.

And then, the other point that you had made, that it is a global world. That we think these diseases don't happen in the United States, but more and more folks are traveling, people are traveling here. With hepatitis A and produce that comes in to the country, certainly, it can happen and it's a good thing to be protected against.

In terms of scheduling that one, it's two doses. Usually, you start it between 12 and 24 months, but you could do it later if you…

Dr. Michael Brady: If somebody has missed, they can certainly get it later.

0:30:06

Dr. Mike Patrick: But ideally, 12 to 24 months is when you would give those two doses.

Dr. Michael Brady: Right. Again, part of that has to do with the fact that at that age, hygiene is not optimal. Again, many of the outbreaks that we're seeing in the United States were in childcare centers. So it was designed to try to make sure of that particular risk population.

And then, one of the things that's kind of interesting is that with hepatitis A, it's very common for young children not to be symptomatic. Whereas, older children and adults are more likely symptomatic. And so, you would have your child in child care, they seem to be doing fine. And then, all of the sudden, there'll be other people in the family who would not be so fine because they have hepatitis.

Dr. Mike Patrick: So, really protecting again at the source of the disease.

The meningococcal vaccine, this is one that we think about kids getting before 7th grade, 11 to 12 years old, or before college. Tell us about that one.

Dr. Michael Brady: Okay. So, there are actually two types of meningococcal vaccines. So, the meningococcus, as we mentioned with the pneumococcus, has a number of different serogroups. The different capsules on the bacteria determine what the serogroup is. And in the United States, the three that are the most common as B, C, and Y. It was relatively obvious, looking at the data, that in young infants, B was the common. And when you got to adolescents, it was C and Y serogroups that were the most common causes of meningococcal disease.

So the first vaccines that became available for meningococcus were vaccines that protected against serogroups A, C, W and Y. And their reasons for that, I mentioned that C and Y cause a lot of disease in adolescents. It cause a little bit of disease in younger children, but it's very high in adolescence. A, which is not something we see in the United States, is actually a serogroup that's present in a number of countries around the world, particularly in Africa. And again, people travel, so it was reasonable to kind of include that.

0:32:37

And so, the original intent of the vaccine when it was created was to try to provide protection to two different groups. There are certain groups of people who are at high risk for meningococcal disease, people with complement deficiencies, people whose cells are not working well, people who don't have spleens or people with sickle cell disease.

There are certain other situations. There might be outbreaks. It turns out microbiologists who work with the organism are at increased risk. And then, if you travel to certain areas, you'd be at an increased risk.

So, the original vaccine was kind of designed for that population. In addition, we recognized that adolescents had a higher rate of meningococcal disease compared to the general population. And when they looked at it, it turned out that college students, particularly those who as freshmen lived in dorms, and as college students frequented areas where there was lots of smoking and alcohol consumption — and so that kind of defines many college students — that they were at increased risk.

So, the original vaccine was going to be given as part of the adolescent platform at 11 to 12 years of age. And there was a hope based on experience from the other conjugate vaccines that protection would last for about 10 to 12 years at least. And that will get people through that peak.

Later, it was determined that the immunity waned in about half the people after four or five years. So it was necessary to have a booster dose. So now what happens is the recommendation is for 11 and then at 16 years of age, and that should cover that increased risk at the time for C and Y, because this is a vaccine with A, C, W and Y.

0:34:36

And that has been very very impactful. We just continued to see a decline in meningococcal disease in that age group.

What's been interesting is B, which I mentioned was the most common serogroup causing meningococcal disease in young infants but was kind of less common in adolescents, there had been at least seven outbreaks on college campuses over the last five years of B. And that was unusual because most of the outbreaks before were C or Y. So probably, the meningococcal conjugate vaccine is protecting college students. And so that means that what's left over is B.

Now, even with those outbreaks on college campuses, there still isn't any increased risk for college students to get meningococcal B disease compared to the general population. Actually, it's slightly lower than the general population. But what's the outbreaks are. That's what serogroup is causing the outbreak and it has got a lot of attention.

Dr. Mike Patrick: Yeah. So will B be added with all the others?

Dr. Michael Brady: So, there currently are two licensed meningococcal B vaccines. And again, they are licensed routinely to be given to individuals who are at increased risk from meningococcal disease. And the vaccines are approved for age ten and above. They are not routinely recommended for any other populations. But the CDC and the American Academy of Pediatrics are going to say that they may be given if the family and the physician feel that it's prudent to give the child the vaccine.

0:36:39

Now, this received kind of complicated recommendation from the CDC. So the CDC has category A recommendations. Those are recommendations that are routine for either an age group or population. So as I mentioned for the meningococcal B, for the high-risk group, got a Category A. For the non-high risk group, they gave it a Category B recommendation, which means that again, if the family and/or the physician feel it would be prudent to give it, the vaccine can be given. And the reason that's important is the Affordable Care Act requires both federal and commercial insurance to pay for any vaccine that has a CDC recommendation.

Dr. Mike Patrick: Whether that's A or B category?

Dr. Michael Brady: Right. So, it's a situation where the B vaccine now is available and cost should not be consideration as to whether or not somebody does or doesn't receive the vaccine. So that's been taken off. And it's just a discussion about risk-benefits and kind of worth it.

Dr. Mike Patrick: So if B outbreaks are now occurring on college campuses and you have a team who's heading off to college, then that would seem that could be a prudent reason to do it.

Dr. Michael Brady: Right.

0:38:04

Dr. Mike Patrick: Do you think that B will be added to the vaccine with A, C, and Y?

Dr. Michael Brady: They probably won't be incorporated into the current ones. So, serogroups A, C, W, and Y, the vaccines are polysaccharide conjugate vaccines where the polysaccharide is part of the capsule, which makes it an A, C, W and Y.

The polysaccharide capsule of B actually looks very similar to polysaccharides that are found in humans. So, the body fortunately will not react to the polysaccharide in meningococcus by developing antibodies because that could damage the person. So they had to come up with a completely different approach, so they took proteins that were in the different meningococcal B strains and develop vaccines from that. And it's unlikely that they would make a good combination with the polysaccharide vaccines.

Dr. Mike Patrick: So that's the reason that there are two different ones and will probably continue to be different ones.

The meningococcal disease itself is not just meningitis. It really can be more severe and rapidly life-threatening. Tell us a little bit about meningococcal disease, why this is an important thing to protect against.

Dr. Michael Brady: So I've mentioned before the term 'invasive'. So when we talk about invasive disease, that means that usually we're concerned about the bacteria getting into the blood stream and then potentially going to other vital areas such as the brain, meningitis or the lungs, pneumonia. With the meningococcus, what happens is the usual preceding situation is that somebody will end up getting exposed to somebody else with a meningococcal strain. It ends getting into their nose. And for reasons that we don't know exactly why, that the bacteria will then invade and get in the blood stream.

0:40:25

Well, it turns out that when this bacteria gets in the blood stream, it gets very aggressive. It grows very quickly. It releases a lot of chemicals that can modify your blood pressure, can modify your heart's ability to function. The bacteria can even go on to damage your adrenal glands and it can also go up to the meninges or around the brain and cause meningitis.

It turns out that probably the thing that is most life-threatening is when the bacteria's in the bloodstream and creating all these chemicals that are damaging your blood vessels and your heart. We call that meningococcemia, and that's where you get this tremendous amount of difficulty maintaining somebody's blood pressure. It's a very rapid process, and it's probably responsible for almost all of the deaths.

Now, some children will also go on to develop meningitis. And, as we mentioned last week, meningitis can result in a lot of significant long-term sequelae, and that can happen with meningococcal disease as well. And so, that's again something that we'd like to prevent.

The other thing that can happen that is really life-changing is that many of the children who have this meningococcemia will also have the bacteria, as well as the impact on the blood vessels cause damage to either the skin or the muscles. We have seen situations where children had to have complete amputation of fingers, toes, but even the whole arms or legs.

0:42:22

So this is a disease that definitely deserves a lot of concern. And if a pediatrician walks in and sees a child with fever, and what we call petechiae, their blood pressure is up too. Because it's something that you recognize as potential from meningococcemia and you've seen patients with meningococcemia, you realize how severe the disease can be.

Dr. Mike Patrick: And you have to react quickly. The mortality rate ends up being about 15% within 12 hours of infection onset without any intervention at all. So it can be rapidly serious and definitely something that you want to protect your kids against.

The final vaccine that I want to cover with the routine childhood vaccines is HPV or the Human papillomavirus. And this one has had a lot of controversy surrounding it, which we'll talk about. But first, why would we want to protect kids against Human papillomavirus? What is it and what does it cause?

Dr. Michael Brady: So, human papillomavirus, again it has a number of different strains or types. The primary thing that we're really concerned about is the possibility that it would cause cancers. And the CDC just recently put out a report and said that each year in the United States, there are about 28,500 cases of HPV-associated cancer.

So it is a significant cause of cancer. And it causes cancer. Believe it or not, the most common HPV-associated cancer now is oropharyngeal cancer. So, 15,000 of the 28,000 are due to oropharyngeal cancer which can occur in both males and females.

0:44:16

The second most common is cervical cancer, followed by vulvar cancer. So those are primarily seen in women. And then, the next highest would be anal or rectal cancers, and then penile cancer. And so, it is a significant cause of cancer, and obviously, we'd like to prevent that.

Dr. Mike Patrick: In boys and girls.

Dr. Michael Brady: In boys and girls.

Dr. Mike Patrick: And I think this is another, we've talked on PediaCast many times about sexual activity in teenagers. The numbers are really probably higher than what most parents would think, where 47% of all high school students admit to having had sexual intercourse at least once in the past. Thirty-four percent admit to having had at least sexual intercourse within the past three months. So, even though you think, "Well, my kid is not going to be sexually active," nearly half of teenagers are. And so, it is really important to get your protected against this to prevent cancer down the road. Would you agree with that?

Dr. Michael Brady: There's no question. The other thing that's very important is that as you mentioned, most parents would not necessarily have thought that the numbers would be as high as they are. But many parents also believe that they could predict what's going to happen in their own children. I think that the fact that they probably would be amazed at the information which suggest that they probably can't.

Dr. Mike Patrick: What timeframe would you give this vaccine?

Dr. Michael Brady: So currently, the recommendation is to give it at age 11 to 12 years of age. But it can be given down to age nine. And actually here at Nationwide Children's Hospital, our primary care network has started giving it at age nine and has had increased acceptance of the vaccine. And giving it at age nine is actually supported by some of the immunologic data that suggest that children between 9 and 13 have much higher levels of antibodies than children and adults over age 13.

0:46:29

So one of the things that giving it an earlier age does is it makes it less likely that the parents are going to have in the back of their mind the issue of sexual activity. Once you get to the point where the child's starts growing through puberty, that becomes much more of a concern. So if you gave it at age nine, I think it is more highly accepted because we've kind of taken away one of the concerns that the parents might have.

Dr. Mike Patrick: One of the confusing things with this vaccine is that there are several types and there are different strains that are involved. So with each one that comes out, there was originally a two-strain one, then a four-strain one. So different serotypes we're talking about that it protects against.

And now there's a nine-strain one that's out there, what if someone had the two or four-strain one, and now they wanted to be protected against those other ones? Can you get the nine-strain one after you've had the other ones? Or, was that not doable?

[Laughter]

Dr. Michael Brady: It's very doable. So if somebody has received the full series of either the HPV2 or the HPV4, they can safely receive the HPV9. Now, neither the CDC or the AAP routinely recommends that because the additional five strains represent less than 10% of the remaining causes of HPV-associated cancers. And from a cost-effective perspective, it doesn't necessarily add up.

0:48:11

However, there are people who are interested in protecting their children as best as possible, and so there will be no reason to not get the other vaccine.

And so, again, it's not routinely recommended but there'd be no reason not to do it.

Dr. Mike Patrick: Is that just the one-booster dose that you would do? Or, would you have to do the whole series? Or, was it just three doses?

Dr. Michael Brady: So currently, it's three. And hopefully, in the not too distant future, it will be two. But you would have to get the full series in order to provide protection.

Dr. Mike Patrick: And I think that the HPV vaccine has really been sort of a victim of the vaccine hysteria that is out there. There had been a lot of claimed associations with Guillain-Barre syndrome, multiple sclerosis, POTS (postural orthostatic tachycardia syndrome), lots of things that folks will come across. But again, it's being monitored, just all the other vaccines that we've talked about. Has there been anything that really does stand up, that this could be an association that's concerning right now?

Dr. Michael Brady: Yeah, so probably the major concern is the issue of syncope. So, you're giving this vaccine to adolescents. We have know for a long time, back when I was training and we used to give a shot of penicillin to treat strep throat, adolescents would faint with that shot as well.

So syncope is probably the biggest risk. And there have been reports of children fainting and hitting their head, hitting their teeth, et cetera. So that's probably the clearest and most significant adverse event associated with giving adolescents any vaccine. But it seems to occur more commonly with HPV vaccine.

0:50:17

And HPV vaccine hurts more than some of the other vaccines, so that's probably the reason. And I can't say for sure but I think that part of the thinking occurs because the adolescent wants to appear strong, and unlike the young child who screams and cries, I think that increases their likelihood that they're going to develop a fainting spell. But that's probably it.

Now, as you mentioned about the monitoring situation, there had been tremendous efforts by the CDC, by the FDA and a number of different situations to try to see if they could identify any associations with many of the different conditions that you've mentioned. And it really turns out that those are sometimes temporally related but not causally related by the vaccine.

That's a tremendously difficult situation for people to understand if they had a child who seemed to be healthy, got a vaccine and then developed that condition, then, why didn't the condition cause it? Well, if they didn't get the vaccine, it probably would have happened anyway. But they didn't have this kind of point in time where they could blame something.

And unless you can, so many of the different conditions you mentioned are things where we might know exactly why they're caused. So it's a lot easier for people to jump on blaming the vaccine when their child experiences a change in their health, and they don't have a good explanation. But, again, using a particularly some very large kind of population databases, the CDC and the FDA can review and take a look at it and make sure that we're not missing something.

0:52:14

Dr. Mike Patrick: So right now and into the foreseeable future, the benefits far outweigh the risks again even with the HPV vaccine, in terms of preventing cancers, which is such an important thing to do. And I guess, in terms of the syncope, it'd be important if you're a parent or a pediatric provider, the teenager getting the shot probably should be sitting down and someone standing next to them and supporting them to prevent falls and hits on the head and chipped teeth and such.

Let's shift gears here a little bit. One of the things that you hear parents say is that are these diseases really still a problem today? So given in particular the diseases that we don't really see anymore, when we did see them it was before the era of modern medicine. So would diphtheria, pertussis, measles, would these things really still be dangerous today? What's your response to that question?

Dr. Michael Brady: So there's no question they would still be as dangerous. Many other things, some of the viral inspection that you mention as we have no specific anti-virals to treat them, we would have slightly better kind of supportive care. And yes, probably there would be a high number of children who would survive but they may still go through a pretty tremendous poor experience and could still end up with significant health complications even if they did survive.

So I think that we're more capable of managing things. But let's take something like meningococcal disease and we talk about how serious it is, the mortality rate hasn't declined despite the fact that we have much better supportive care. And part of the reason is that the disease that really progresses so rapidly, that before we'd have the ability to kind of use some of our very valuable supportive care mechanisms, the situations already become to a point where it can't be reversed or the child comes in to the emergency room pretty much dead.

0:54:33

Dr. Mike Patrick: So these really are diseases that we don't want to come back and have to deal with. And there's a cost involved that goes beyond just the mortality whether a child dies from a disease, but really, what the child goes through just comfort-wise, what the family goes through, the financial cost to the disease itself. And so, really, these vaccines are still very important today.

Are we giving too many vaccines? That's another common complaint of parents, that there are just too many of them that the kids are getting. Well, how do you address that?

Dr. Michael Brady: As a person who has seen the value of vaccines, I'm actually excited that we may be able to give more vaccines. There's some promising information about the potential RSV vaccine.

So, the situation that parents are concerned about is two-fold. One is the number of shots. And there's no question, parents don't want to see their children get stuck. It hurts. But there's actually been some nice studies where they've shown that using cortisol and some other markers of stress, that if a child gets three shots or one shot, they actually have the same amount of stress. And so, spreading the vaccines out and given them only shot each time just causes them to have stress more often than giving them multiple shots at one time.

So I can understand why parents are not excited about their child getting stuck at different places, but fortunately, they go through a stressful period but then they recover very quickly, and it's over. And if they were to get the disease that's prevented, they wouldn't be that lucky.

0:56:16

The other situation is they think about these vaccines having these antigens which is what stimulates the immune system. And that maybe we're getting exposed to too many of these at one time and it's going to overwhelm the immune system of that child. Well, if anybody has taken a look at an immunology textbook in 2016, they would realize that the immune system is a very, very intricate but very, very capable system that can actually multi-task much better than anybody. And what happens is the immune system has the capability of recognizing thousands and thousands of antigens at one particular time and making the right decisions about what it needs to do.

Well, if you go back and take a look, I mentioned about the pertussis vaccine where we used the whole pertussis organism. If you go back and look at how many antigens that we were exposing children in the 1960s. And then you take a look at how many antigens we're exposed into in 2016, we are many, many times lower amount of antigens, because of the processing of the vaccines now allows them to kind of reduce the number of antigens, make them cleaner, et cetera.

So their immune system wasn't getting overwhelmed in the 1960s when we didn't get that many vaccines. It certainly isn't getting overwhelmed now. The other thing is, if somebody gets a strep throat, the amount of antigens that they get exposed to by the streptococcus being there actually far exceeds how many antigens with all the vaccines we have together put in one.

0:58:09

So the body has developed the ability to be exposed to multiple antigens, to be able to figure out how to address each one independently and come up with an immune response. Now, the other things we have to recognize is when we give these vaccines, the schedule is made after the companies that make the vaccines have done studies showing that when you give a single vaccine, and then when you add a new one to it, or two or three or four, that the immune response for each one of them is not changed by being in the same schedule that they would be if they were independent and were given one at a time.

So there's no advantage of separating the vaccines out with respect to the ability for the body to see them and develop a protective response. And as I mentioned if you do spread them out, you're just making your child stressed more frequently.

So, it really is done with a good amount of information to support the fact that the vaccines when given together result in the same level of response as if they were given separately.

Dr. Mike Patrick: And when you do give them separately, so if you're talking about an alternative immunization schedule that kind of spreads things out more, not only are your kids getting shots more often, but also you're allowing them to be susceptible to whatever disease for a longer period of time before they have good full protection.

Dr. Michael Brady: Right. So first of all, we're trying to get away from alternative schedule because that would suggest that it's an option. And we're trying to see that there is a proven recommended schedule and all our schedules are therefore unproven and not recommended. And so, what you said is exactly the reason that if you space out the vaccine, you actually increase the amount of time that somebody might be susceptible. Because, the schedule is made based on understand the epidemiology of the diseases and when you would like to get protection and how you can get protection in the most effective way to try to protect the child.

1:00:33

Now, the other thing is many of the people who are opposed to vaccines have recommended that the proven recommended schedule be compared to another schedule. And the Institute of Medicine actually specifically said that would be unethical because any schedule that does expand the time of risk would not be appropriate to do a study.

So we aren't going to see that study because it wouldn't be ethical. And that I think supports the fact the proven recommended schedule is the right schedule.

Dr. Mike Patrick: Yeah. Because in order to show that the alternate schedule is dangerous is to put kids at risk. And then the kid gets meningitis from Haemophilus, for instance, or gets measles and has a bad outcome, then that's the reason it's unethical. Because we don't want to put those kids' lives at risk, which is what parents are doing when they go with alternate schedules.

Dr. Michael Brady: Right. And again, we saw what the situation is with Disneyland measles. But in 2010 or '11, when California had a large pertussis outbreak, that's exactly what they saw. Was that the pertussis disease was occurring in those children who are unimmunized or underimmunized. And so anytime that you prolong a period of risk, you're going to accept that risk.

1:02:03

Dr. Mike Patrick: We really appreciate you stopping by today and talking about immunizations.

I want to remind folks that Part 1 was last week, so we've really had a couple of hours of immunization talk. And I hope this is useful for folks as you're thinking about immunizations and how they work and the diseases that they protect against and why kids get so many of them, because we care about kids and want to protect them against these diseases.

In Part 1 last week, we covered hepatitis B, diphtheria, tetanus and pertussis, or the DTaP vaccine. Also the Tdap vaccine, Hib or Haemophilus influenzae type b, the polio vaccine, rotavirus and the pneumococcal shot as well. Last week, we also answered the question, how exactly do vaccines work, what benefits do they provide? We explained the concept of herd immunity or community protection, and we explored the real risks of immunizations because we want to be transparent about that. Just like driving in your car, nothing is a 100% safe, but the risks are extremely low. And we outlined what those risks are in our previous episode and kind of walked through a risk-benefit analysis of the vaccine decision.

So be sure to check out our previous episode if you haven't already, PediaCast 351, which was Childhood Vaccines Part 1.

Also, I want to thank Dr. Michael Brady again, pediatric infectious disease specialist here at Nationwide Children's Hospital and a candidate to be the next president of the American Academy of Pediatrics. Thanks so much for stopping by today.

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1:06:03

And while you have your providers' ear, let them know we have a podcast for them as well — PediaCast CME. That stands for Continuing Medical Education. Similar to this program, we do turn up the science a couple of notches and provide free Category 1 CME Credit for listeners. Shows and details are available at PediaCastCME.org.

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Thanks again for stopping by, and until next time, this is Dr. Mike, saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.

[Music]

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.